Multispecialty Treatment of Dural Arteriovenous Fistulas: Embolization, Craniotomy and Radiosurgery David Barnett, MD Chief of Neurosurgery Baylor University.

Slides:

Advertisements

Similar presentations

Radiology Case Presentation David R. Beckert, MS-4 11/8/05.

Advertisements

Mechanical Injuries Of Brain and Meniges.

Brain Arteriovenous Malformations in Adults Eric Johnson OHSU MS3 12/14/07 Eric Johnson OHSU MS3 12/14/07.

Morning Report: Tuesday, March 6th. AKA: Pseudotumor Cerebri.

DURAL ARTERIOVENOUS MALFORMATIONS Issam A. Awad, MD, MSc, FACS, MA(hon) Professor of Neurosurgery Evanston Northwestern Healthcare Feinberg School of Medicine.

Outcome after interventional or conservative management of unruptured brain arteriovenous malformations: a prospective, population-based cohort study Lancet.

Cerebral Vein Thrombosis Morning Report Sima Patel 5/13/09.

Online Module: Pseudotumor Cerebri

Consultant Neuroradiologist

HEADACHE IN THE SEVERELY OBESE Harvey Sugerman, MD, FACS, FASMBS Editor: Surgery for Obesity and Related Diseases Co-owner, Chief Medical Officer: Spark.

Postoperative Intracranial Hemorrhage after Obliteration of Traumatic Carotid Cavernous Fistula with Total Steal of Blood Flow Department of Neurosurgery,

Dural Arteriovenous Fistulae Static or Dynamic? Cognard et al –seven patients with documented worsening of venous drainage –aggressive natural history.

Andres RH, Guzman R, Remonda L†,

SPINAL DURAL ARTERIOVENOUS FISTULAE: MR IMAGING CHARACTERISTICS AND CLINICAL SIGNIFICANCE PATRICK DO, MD JEFFREY DORR, MD PRIYA KRISHNARAO, MD MAHESH PATEL,

Grand Rounds Conference Reema Syed, MBBS University of Louisville Department of Ophthalmology and Visual Sciences October 16, 2015.

Cerebral Blood Circulation

ANTERIOR VENOUS MALFORMATION (BRAIN)

Tentorial Meningiomas.  Meningiomas of the posterior cranial fossa account for ~9% of all intracranial meningiomas.  Approximately 3 to 6% of all intracranial.

Dural AVF 52 year old right-handed gentleman with 3 month history of worsening unsteadiness. ROS significant for left pulsatile tinnitus over past 2 years.

Petroclival meningiomas. Anatomic landmarks The clivus – localization: Part of the skull base, behind the dorsum sellae. The posterior end of the midline.

Wessam Mustafa, Krzysztof Kadziolka, Laurent Pierot,

Angel Mironov Creighton University Medical Center Omaha, Nebraska.

Unusual Acute Complication Of Carotid Cavernous Fistula Fong Y Tsai,MD FACR UCI Medical Center, Orange,Ca. USA.

Symposium Neuroradiologicum, Bologna, F. Signorelli, P. Khoueir, F. Scholtes, D. Roy, M.W. Bojanowski – Dural AV fistulae and Dementia Dural.

Cerebral venous sinus thrombosis

UNUSUAL CAROTID CAVERNOUS SINUS FISTULA ANIL KARAPURKAR Sir H N HOSPITAL MUMBAI.

Parallel Dural Sinus Dural AV Fistula: Diagnosis and Treatment Hon-Man Liu, MD,MBA National Taiwan University Hospital Taipei, Taiwan Conflict of interest:

CEREBRAL VENOUS THROMBOSIS

ENDOVASCULAR TREATMENT (EVT) OF BRAIN AND DURAL MALFORMATIONS (AVM) USING ONYX IN A SINGLE CENTER EXPERIENCE,N.SOUROUR MD,M.MUSACCHIO MD,A.LEBEDINSKY MD,N.HIROTA.

Imaging of radiosurgical planning and follow-up of arteriovenous malformations treated by gamma knife: ten years experience. P.David*, N.Massager**, N.Sadeghi*,

Embolization of Carotid Cavernous Fistulae by transvenous approach through the Facial Vein Chao-Bao Luo, Michael MH Teng, Feng-Chi Chang, Wan-You Guo Department.

Mahmoud Zahra MD, Ganesh Krishnamurthy, MD ; Anne Marie Cahill, MD, Hamza Shaikh, MD, Storm, Phillip, MD, Robert W. Hurst, M.D.

R. Shane Tubbs, MS, PA-C, Ph.D.

ACUTE STROKE Alexa Lauch IMG 310 Summer Semester 2016.

Dural Arteriovenous Fistulas (dAVFs) Βασίλειος Ραπτόπουλος Νευροχειρουργική κλινική ΓΝΑ «Γ.Γεννηματάς»

Spontaneous resolution of prenatally detected dural sinus thrombosis: Case series and review of the literature 1 Hoetschl, J., 1, 2 Bamfo, J. E. A. K.,

Carotid cavernous fistula: an easily missed

Transvenous AVM Embolization: is it a solution for AVM treatment?

CEREBRAL BLOOD CIRCULATION

CEREBRAL BLOOD CIRCULATION

Embolization in the External Carotid Artery

Blue rubber bleb nevus syndrome: a tale of two eyes

(dural arteriovenous fistula)

Temporal Changes and Spectrum of Findings on Follow-up CT Angiogram in Patients with Suspected Post-traumatic Blunt Cerebrovascular Injury.

Common Clinical Presentations and Clinical Evaluation in Orbital Diseases Dr. Ayesha Abdullah

Arterial Blood Supply of the Brain

Endovascular repair of subclavian artery complex pseudoaneurysm and arteriovenous fistula with coils and Onyx Nana Amiridze, MD, PhD, Yougi Trivedi,

Neurofibromatosis-associated massive right internal carotid artery aneurysm with a coexisting arteriovenous fistula Marlin Wayne Causey, MD, Daniel M.

Time-Resolved Magnetic Resonance Angiography in the Evaluation of Intracranial Vascular Lesions and Tumors: A Pictorial Essay of Our Experience Ming-Cheng.

Brain Vasculature.

A 43-year-old woman with Factor V Leiden mutation developed a spontaneous left-sided dural type (indirect) carotid cavernous fistula (CCF) with proptosis,

A 58-year-old male patient presented with thunderclap headache and a small subarachnoid hemorrhage centered at the foramen magnum. A 58-year-old male patient.

Endovascular Treatment of Intracranial Aneurysms

Schematic overview of the Borden system of classification for DAVFs

Serial imaging of a girl with an extensive left orbitofrontal lymphatic malformation associated with a left posterior dural AV fistula, dural sinus enlargement,

A 55-year-old patient with a history of intraparenchymal hemorrhage on CT of the head (A) related to a right transverse–sigmoid dural arteriovenous fistula.

A, Coronal 3-mm-slab MIP from CTA in patient 3 with a right transverse sinus DAVF, predominantly supplied by right occipital, middle meningeal, and marginal.

Endovascular therapy in DAVFs in 2 different patients (A−C and D−F, respectively). Endovascular therapy in DAVFs in 2 different patients (A−C and D−F,

A 52-year-old man presented with severe headache, slurred speech, and acute left hemiparesis. A 52-year-old man presented with severe headache, slurred.

Left transverse sigmoid DAVFs (type IIa) with 3 shunted venous pouches

A 58-year-old man (patient 1) with a good-grade (Hunt and Hess II) subarachnoid hemorrhage from a torcular DAVF that was cured with a single Onyx injection.

62-year-old woman with incidentally discovered bilateral cavernous sinus aneurysms. 62-year-old woman with incidentally discovered bilateral cavernous.

A, Right common carotid artery injection demonstrates massively enlarged inferolateral and meningohypophyseal trunks feeding a tentorial dural arteriovenous.

A 69-year-old patient with subarachnoid and intraventricular hemorrhage on CT of the head (A). A 69-year-old patient with subarachnoid and intraventricular.

A, Anteroposterior (top row), lateral (second row), and axial (bottom row) projections of maximum-intensity 4D-CE-MRA images (2.9/1.4, 20° flip angle)

A 60-year-old man presented with symptoms of decreased visual acuity, exophthalmos, and chemosis of the left eye of 1 month’s duration.A, Initial left.

A 51-year-old man (patient 7) after 3 unsuccessful endovascular treatment attempts 10 years ago showing a progressive Borden I fistula on the right. A.

An unresponsive 42-year-old patient with seizure.

Case 23, a patient with treated DAVF with residual Borden type I shunt

Presentation transcript:

Multispecialty Treatment of Dural Arteriovenous Fistulas: Embolization, Craniotomy and Radiosurgery David Barnett, MD Chief of Neurosurgery Baylor University Medical Center August 13, am

2

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Goals What is a Dural Arteriovenous Fistula (DAVF)? How do they present? What constitutes a potentially dangerous DAVF? The roles of the different treatment options. 3

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Definition of DAVF An arteriovenous shunt in which the nidus is solely contained within the leaflets of the dura mater. Also referred to as Dural Arteriovenous Malformation (DAVM). 4

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Background 10-15% of all intercranial AVM More common in women Mean age at presentation is fifties Rare in children 5

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Pathogensis Not completely understood Most popular theory is collateral revascularication (i.e. sinus thrombosis followed by recanalization of the dura) Precipitating factors include…trauma, hypercoagulable states, and infection 6

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Presentation Highly variable Location, location, location Pulsatile tinnitus, Bruit, Headache Opthalmoplegia, Chemosis, Proptosis Papilledema Focal or Global Neurologic Deficit Intracranial hemorrhage 7

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Radiographic Evaluation CT/CT Angiogram, MR/MR Angiogram Initial investigation Abnormal blood vessels, white matter edema, hemorrhage Cannot exclude DAVF Intracranial Angiography The Gold Standard Accurate classification 8

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Hallmark Angiographic Feature Premature appearance of venous structures Within or next to the dura during the arterial phase 9

10

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Arterial Supply Arterial branches that supply the dura Middle menigeal artery Anterior Fossa: Ethmodial branches of the opthalmic artery Cavernous Sinus: Dural branches from ICA and accessory menigeal branch of the maxillary artery Posterior Fossa: Dural branches of vertebral, occipital, and ascending Pharyngeal Arteries 11

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Location of DAVF AWAD and Little: J Neurosurgery 1990; 72: Review of Literature with 377 DAVF cases 12 Aggressive / Benign Transverse/ Sigmoid Sinus62.6%1:8.8 Cavernous Sinus11.9%1:6.5 Tentorial Incisura8.4%31:1 Convexity Sagittal Sinus7.4%1:1 Anterior Cranial Fossa3.7%2.1:1 Sylvian – Middle Fossa3.7%2.5:1

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Classification Anatomic Location Associated Dural Sinus Hemodynamics Venous Drainage Pattern Aggressive / Benign 13

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Angiographic Classifaction Borden 3 types based on cortical venous reflux and sinus drainage Cognard 5 types based on cortical venous reflux, sinus drainage and direction of flow with involved sinus Barrow Used for Cavernous sinus fistulas 14

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Borden Classification (Journal of Neurosurgery 1995; 82: ) Type 1:Anterograde sinus flow and no cortical venous reflux Type 2:Retrograde sinus flow and cortical venous reflux Type 3:No flow inside the sinus and exclusive cortical venous reflux 15

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Cognard Classification (Radiology 194(3): , 1995 Type 1: Drainage into venous sinus only; anterograde flow Type 2A:Draining into dural sinus with retrograde flow Type 2B:Anterograde drainage into sural sinus and CVR Type 2A & B:Retrograde drainage into dural sinus and CVR Type 3:CVR only without venous ectasia Type 4:CVR only with venous ectasia Type 5:Drainage into spinal perimedullary veins 16

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Natural History (Interventional Neuroradiology 1997; 3: ) Aggressive presentation Intracranial Hemorrhage, Focal Neurologic Deficit or Death Borden Type 12% Borden Type 239% Borden Type 379% Borden Type 2 & 319.2% / patient-year ICH 17

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Bottom Line Presence of retrograde cortical venous drainage is significant prognostic factor for aggressive or unfavorable natural history 18

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Treatment Options Observation Medical Management Endovascular Transarterial Transvenous Liquid Embolic, Coils, Stents 19

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Treatment Options Continued Surgery Exposure Ligation, Resection or Disconnection of DAVF Stereotactic Radiosurgery Gamma Knife Cyber Knife Novalis Combination Endovascular, Surgery, Radiosurgery 20

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Management Goals Identify which DAVFs are potentially aggressive Determine when to treat and which treatment method to use Partial vs. Complete obliteration 21

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Cases 22

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Case 1 Type 1 DAVF Sigmoid Sinus DAVF 52 year old male presents with pulsatile tinnitus and occipital bruit Past medical history significant for Nephrotic Syndrome, Antithrombin III deficiency and dural sinus thrombosis 23

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas 24

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas 25

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Case 2 High Flow Indirect Carotid Cavernous Fistula with Exclusive Cortical Venous Drainage 71 year old presents with progressively worsening diplopia, left eye chemosis and blurred vision Had seen several ophthalmologists Increased intraocular pressure 26

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas 27

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas 28

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Case 2 - Outcome High Flow Indirect Carotid Cavernous Fistula with Exclusive Cortical Venous Drainage Full Recovery 29

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Case 3 High Flow DAVF at the Sinus Torcula 21 year old female presents with severe medically recalcitrant headaches and progressive blindness Previously diagnosed and treated for pseudotumor cerebri Bilateral optic nerve fenestrations 30

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas 31

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas 32

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Case 3 - Treatment High Flow DAVF at the Sinus Torcula Staged 3 preop embolizations Bilateral Occipital and Suboccipital Craniotomies and intraoperative angiograms Gamma Knife Radiosurgery 33

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas 34

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas 35

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Case 3 - Outcome High Flow DAVF at the Sinus Torcula Overall excellent Developed radiation necrosis 3 years later and lost some vision Completed college and now 5 years later, is engaged and in the working world 36

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Case 4 Left Transverse Sinus DAVF with CVR 60 year old male presenting to outside hospital with severe headache and visual loss MRI: Left Occipital hemorrhage and abnormal flow voids 37

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas 38

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas 39

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Case 4 – Treatment & Outcome Left Transverse Sinus DAVF with CVR Transvenous embolization Full Recovery 40

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Case 5 High Flow Direct CCF 27 year old female presents with headache, right eye proptosis and ecchymosis and right temporal bruit Patients medical history significant for motor vehicle collision and craniotomy at outside hospital one month before 41

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas 42

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas 43

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas 44

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas 45

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas Case 6 High Flow DAVF with CVR 37 year old female presents with right sided weakness and expressive aphasia for one day duration Patient’s medical history: Diabetes 46

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas 47

© 2005 Baylor Health Care System August 13, 2013 Multispecialty Treatment of Dural Arteriovenous Fistulas 48